Course Re-Certification Checklist
Complete this checklist to verify fulfillment of all requirements for course re-certification.
Participant Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Course Title
*
Course Code or Reference Number
Date of Original Certification
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Re-Certification Submission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Checklist: Please indicate which requirements have been completed.
*
Rows
Completed
Not Applicable
Proof of prior certification attached
1
2
Minimum required training hours met
3
4
Assessment/exam passed
5
6
Updated policy review completed
7
8
Continuing education documentation provided
9
10
Attendance records submitted
11
12
Supervisor approval obtained
13
14
Upload Supporting Documents (if applicable)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional Comments or Notes
Staff/Instructor Name (if applicable)
First Name
Last Name
I confirm that the information provided is accurate and all re-certification requirements have been met.
*
Yes, I confirm
No, I do not confirm
Submit Checklist
Should be Empty: